Debilitating body image disorder often begins in teens; likely to be missed

A new study of 33 children and adolescents with body dysmorphic disorder - the
largest study ever conducted on this age group - found subjects dropping out of
school, becoming reclusive and attempting suicide.

PROVIDENCE, R.I. -- Teen-agers' concerns with their appearance should not be
dismissed lightly. The image obsession known as body dysmorphic disorder (BDD)
typically begins in young people and left untreated may lead to impairment in
functioning and even to suicide attempts, according to a new study by Brown
University researchers, the largest study ever conducted on this age group.

In an analysis of 33 children and adolescents diagnosed with BDD (a
preoccupation with nonexistent or slight defects in appearance), 94 percent
reported impairment in social functioning; 39 percent had been hospitalized;
and 21 percent had attempted suicide.

A specific class of antidepressants - serotonin reuptake inhibitors - proved
effective in reducing the BDD symptoms for 53 percent of the participants who
took them, said study authors Ralph S. Albertini, M.D., and Katharine A.
Phillips, M.D., in the April Journal of the American Academy of Child &
Adolescent Psychiatry.

The study consisted of 30 females and three males, aged 6 to 17. It is
estimated that BDD begins before age 18 in 70 percent of cases, most commonly
at age 13. The subjects had been referred for evaluation and treatment to a BDD
clinical and research program at Butler Hospital in Providence, R.I., by
community therapists, parents or by themselves.

Sixty-one percent of bodily preoccupations focused on the skin; 55 percent
on hair; 48 percent on weight; 39 percent on the face; 30 percent on teeth; 27
percent each on legs and nose. All body parts of concern to the subjects
appeared to the interviewers to be normal or to have only minimal anomalies.

Most participants spent more than three hours a day thinking about their
perceived defects; some said it was all they thought about. Many avoided making
friends and dating. Eighty-five percent reported the disorder interfered with
academic performance, with those at the extreme end - 18 percent - having
dropped out of school. One middle school student had missed more than 100 days
of the previous school year because of BDD.

All subjects had associated compulsive behaviors - most often camouflaging
the perceived defect with clothes, makeup, or a hat or repeatedly checking
mirrors and other reflective surfaces. One patient asked, "Mom, do you think
the gap between my front teeth has gotten any wider?" up to 30 times a day.

About half of 19 subjects treated with serotonin reuptake inhibitors
experienced a decrease in preoccupation, distress and compulsive behavior and
reported improved functioning, researchers found. Subjects responded to the
antidepressants after four to 16 weeks of treatment. Many were able to resume
normal activities with peers and improve school attendance. Other psychiatric
treatments, undertaken by 55 percent of the participants, were generally
ineffective, and 36 percent of subjects who received surgical treatment for
their perceived flaws had no improvement in symptoms.

Diagnosis of BDD in young people often requires inquiries about specific BDD
symptoms because young people are often too embarrassed to divulge them, say
the researchers. For example, it may be worthwhile for parents and medical
personnel to ask "Is there some aspect of your appearance that you're really
unhappy about?" Concerns about appearance are not sufficient for diagnosis
unless they cause significant distress or impairment in functioning. "The
problem is that adolescence is when this usually begins and it's not being
picked up... people see it and trivialize it," said Phillips. "This is not just
a phase."

Larger studies on children and adolescents with BDD, including treatment
studies with control groups, now need to be done, say researchers. Studies that
use a community sample would likely have a more balanced sex ratio than this
study. The imbalance likely occurred because patients were recruited from a
psychiatric population.

The study was supported by an unrestricted grant from Solvay
Pharmaceuticals. Albertini, clinical assistant professor of psychiatry, and
Phillips, associate professor of psychiatry, have faculty appointments in the
Brown University School of Medicine.